A list indicating the full (legal) name, date of birth and gender of each of the corporation's officers and directors, and whether each officer and director holds a valid security clearance.

List of directors and officers attached

A copy of the certificate of incorporation or other constituting instrument.

Certificate attached

If applicable, a copy of any document that states the applicant's name that has been filed with the province where the proposed site is located. This includes any document that references any other name registered with the province, under which the applicant intends to identify itself or conduct the proposed activities.

Document(s) attached

3. Proposed Personnel

3.a. Proposed Senior Person in Charge (Senior PIC)

The Senior Person in Charge will have overall responsibility for management of the activities carried out by the licensed producer under their licence at their site -- who may, if appropriate, be the licensed producer. Please identify the proposed Senior Person in Charge. The Senior Person in Charge will have the authority to bind the applicant.

Surname: Given Name(s): Other Title:

Gender:

M

F

Date of Birth (YYYY/MM/DD):

Telephone No.: Fax No. (if applicable):

Email:

3.b. Proposed Responsible Person in Charge (RPIC)

The Responsible Person in Charge will work at the licensed producer's site and have responsibility for supervising the activities with respect to cannabis conducted at that site by the licensed producer under their licence, and for ensuring that the activities comply with all relevant Acts and regulations. This person may be the same as the Senior Person in Charge.

3.c. Proposed Alternate Responsible Person in Charge (A/RPIC)

The applicant may designate one or more Alternate Responsible Person in Charge to work at the proposed site and replace the Responsible Person in Charge when that person is absent. The Alternate Responsible Person in Charge will work at the licensed producer's site, in the absence of the RPIC, and have responsibility for supervising the activities with respect to cannabis conducted at that site by the licensed producer under their licence and for ensuring that the activities comply with all relevant Acts and regulations.

If more than one A/RPIC is proposed, additional pages must be attached for each one.

The individuals identified above must hold a valid security clearance. A producer's licence will not be issued if all the security clearances required under the MMPR have not been granted.

The individuals identified above must submit a piece of valid photo identification.

If any of these individuals already hold a valid security clearance, please attach the confirmation of the security clearance to the application.

If any of the individuals listed above do not already hold a valid security clearance, they will be required to complete the Security Clearance Application Form. The form can either be sent with the completed application, or it can be sent separately. If sent separately, please attach a note to clearly indicate under which name and for which site (if applicable) the application was made. The Security Clearance Application Form can be found online.

Note: Applications will not be processed until all completed Security Clearance Application forms associated with this application have been received.

As part of the Security Clearance Application process, each of the individuals identified above will also be required to complete the Security Clearance Fingerprint Third Party Consent to Release Personal Information form that will allow a Canadian police force or a fingerprinting company accredited by the RCMP to submit fingerprints to the RCMP for the purposes of a criminal record check. A list of agencies accredited by the RCMP can be found online. The Security Clearance Fingerprint Third Party Consent to Release Personal Information form can be found online. You need to provide a copy of these forms as part of your application.

b) Sale or Provision (Please refer to the MMPR for information about to whom you can sell or provide.)

c) Shipping, Transportation or Delivery

d) Destruction

e) Production

5.a.i. Quantity of Dried Marihuana to be Produced (if applicable)

Please indicate the maximum quantity (expressed as the net weight in kilograms) of dried marihuana to be produced and the production period.

Quantity of Dried Marihuana to be Produced

Quantity of dried marihuana to be produced (kg)

Production Period(s) involved

5.a.ii. Quantity of Dried Marihuana to be Sold or Provided to Eligible Persons Under the MMPR (if applicable)

Please indicate the maximum quantity (expressed as the net weight in kilograms) of dried marihuana to be sold or provided to eligible persons and the period in which that quantity is to be sold or provided.

Quantity of Dried Marihuana to be Sold or Provided to Eligible Persons

Quantity of dried marihuana to be sold or provided (kg)

Period(s) involved

5.b. Activities With Cannabis, Other than Marihuana

Complete this section if you intend to conduct activities with cannabis derivatives, preparations and similar synthetic preparations, other than marihuana (e.g. in order to conduct in vitro testing to determine the percentages of cannabinoids in dried marihuana).

Please check the box(es) of proposed activities that you intend to carry out using cannabis, other than marihuana. Please also indicate the: substance description; building where the activities will take place; and purpose for conducting each of the activities.

I do not intend to conduct activities with cannabis, other than marihuana

Please provide the name, contact information, and Controlled Drugs Dealers License number for the laboratory performing third-party testing your cannabis product in your application form. An acceptable analytical testing laboratory must possess a Health Canada dealers licence that would authorise the possession or handling of this material. If you have not identified a suitable laboratory and would like to receive a list of licensed dealers authorised for the analytical testing of cannabis please contact the Licenses and Permits Division at MMPR-RMFM@hc-sc.gc.ca.

Site information:

Building Information (if applicable):

If the proposed site is comprised of more than one building in which proposed activities are to be conducted, please provide information on each building. For multiple buildings, attach additional sheets as required.

As per subsection 26(2), an assessment is done to evaluate the likelihood the production site in question would create a risk to public health, safety, or security, including the risk of cannabis being diverted to an illicit market or use. Documents required to help determine the risk to public health, safety and security include;

An up-to-date building location survey, prepared and certified by a qualified surveyor. The survey document must show the lot dimensions and the relative location and dimensions of all buildings and improvements to the property as well as easements, right-of-way and other property interests as they currently exist.

The legal zoning of the proposed site and adjacent lots

A recent aerial view (e.g., an aerial photograph or other imagery) of your proposed site showing surrounding lots within a radius of 500 meters from your proposed site

These documents allow a more in depth assessment to identify whether or not a proposed site is suitable.

7. Ownership of Property

If the applicant is the owner of the entire proposed site, the declaration in section 7.a. is to be signed by the proposed Senior Person in Charge (Senior PIC).

If the proposed site or any portion of the site is not owned by the applicant, a declaration signed and dated by the owner(s) of the site or each portion of the site must be submitted along with this application consenting to the use of it by the applicant for the proposed activities. (See Appendix A)

Appendix A attached to this form

7.a. Applicant and Site Owner's Declaration

I hereby declare that the entire proposed site, mentioned herein within this application, on which the proposed activities are to be carried out, is entirely owned by the applicant for this license under the Marihuana for Medical Purposes Regulations.

Surname of site's Senior PIC: Given Name(s): Other Title (e.g. President): Signature of the site's Senior PIC: Date: (YYYY/MM/DD)

8. Proposed Site and Physical Security

Please attach a detailed description of the security measures and floor plans of the site, including each of the building(s) within the proposed site within which any licensed activities are to be conducted:

9. Notice to Local Government, Police and Fire Authorities

Before submitting this application, a notice that includes the proposed activities to be conducted with cannabis and the address of the site(s) and of each building within the site(s) must be provided to a senior official of the local police, local fire authority and local government.

Please identify below the names of the senior officials within your local police, local fire authority and local government to whom you have provided notifications. Please also attach a copy of each notice to this application. These senior officials may be contacted by Health Canada to confirm that they have received these notices. . Santé Canada pourrait communiquer avec ces personnes pour confirmer qu’elles ont bien reçu l’avis.

Copies of all the notices are attached

Police Force

Local authority: Name of senior official: Title: Address: Date provided:

Fire Authority

Local authority: Name of senior official: Title: Address: Date provided:

Local Government (e.g. Municipality)

Local authority: Name of senior official: Title: Address: Date provided:

Declaration to be completed by the Senior Person in Charge

I hereby declare that written notices containing the information referred to in this application regarding proposed activities regulated under the MMPR have been provided to the senior official of the local authorities listed above:

10. Quality Assurance Pre-licensing Report

The applicant must submit a document signed and dated by the proposed quality assurance person that includes:

a description of the quality assurance person's qualifications in respect of the proposed licensed activities and the requirements of the MMPR; and,

a report establishing that the buildings, equipment and proposed sanitation program to be used in conducting the proposed activities referred in the MMPR comply with regulatory requirements.

Note: The accuracy of the information in the report will be verified by Health Canada inspectors during the pre-licence inspection of the proposed site.

Detailed description of the quality assurance persons qualifications included

Building, equipment and sanitation program provided

Document signed and dated by the proposed quality assurance person attached

Surname: Given Name(s): Other Title:

Gender:

M

F

Date of Birth (YYYY/MM/DD):

Proposed Schedule  Work Hours and Days (e.g. 8am  4pm, Mon  Fri)

11. Record Keeping

Please provide in an attachment a detailed description of your proposed record keeping methods. Your proposed record keeping methods must comply with and will be evaluated for compliance with Part 6 of the MMPR.

If available, you may choose to also submit examples of the documents you are planning to use to ensure proper record keeping.

12. Declarations and Attestations

The following declarations and attestations must be signed and dated by the Senior Person in Charge.

I hereby declare that the proposed Senior Person in Charge (Senior PIC), the proposed Responsible Person in Charge (RPIC), and if applicable, the proposed Alternate Responsible Person(s) in Charge (A/RPIC) are familiar with the provisions of the Controlled Drugs and Substances Act and its regulations and the Food and Drugs Act that will apply to this licence.

I hereby declare that the entire proposed site, mentioned herein within this application, on which the proposed activities are to be carried out, is not a dwelling-place.

I hereby attest that all of the information and documents submitted in support of the application are, to the best of my knowledge, correct and complete.

I hereby attest that I have the authority to bind the applicant.

Surname of Senior PIC: Given Name(s): Other Title (e.g. President): Signature of Senior PIC: Date: (YYYY/MM/DD)

13. Submission

Please take note that all mandatory information and documents requested must be provided to avoid delay of processing this application. Your application may be returned to you if it is incomplete. Please send the completed Application Form and accompanying documents to the Office of Controlled Substances at the following address:

Health Canada A.L.: 0300B Ottawa, ON KIA 0K9

A Health Canada representative is available to assist you if you have any questions pertaining to these requirements and the application process. You can send us your questions by email at MMPR-RMFM@hc-sc.gc.ca or call us at 1-866-337-7705.

Appendix A

Consent by Owner to Utilize Site

If the proposed site, or any portion of the site, identified below is not owned by the applicant, this declaration is to be signed and dated by the owner of the site (or each portion of the site). The owner must consent to the use of the site by the applicant for the proposed activities with cannabis.

If there are multiple owners, each owner must consent to the use of the site by the applicant for the proposed activities with cannabis using part (2) b) of this Appendix. Please attach additional pages as needed.

Check here if additional pages are attached

(1) To be completed by the applicant:

Please provide a brief description of the activities to be conducted on the proposed site or any portion of the site for which this consent is being requested.

Description of Activities to be Conducted with Cannabis on the Proposed Site:

Location of proposed site for which consent is being requested:

Street Address

City

Province

Postal Code

(2) To be completed by site owner(s):

(2) a) Sole owner

I hereby declare that I am the sole owner of the proposed site listed in section (1) of this Appendix and that I am fully aware of and consent to the activities with cannabis described in section (1) of this Appendix being conducted on this site.

Signature: Date: (YYYY/MM/DD) Print Full Name:

Note: If the owner is company, please submit a signing authority document.

(2) b) Joint Owner(s)

Note: If the site is co-owned, please provide the name and address for each property owner.

Property Co-owner (1)

Full Name: Address:

Property Co-owner (2)

Full Name: Address:

Property Co-owner (3)

Full Name: Address:

Property Co-owner (4)

Full Name: Address:

I hereby declare that I am a co-owner of the proposed site listed in section (1) of this Appendix and that I am fully aware of and consent to the activities with cannabis described in section (1) of this Appendix being conducted on this site.

Please do not include sensitive personal information in the message box, such as your name, address, Social Insurance Number, personal finances, medical or work history or any other information by which you or anyone else can be identified by your comments or views.

Any personal information collected will be administered in accordance with the Department of Employment and Social Development Act, the Privacy Act and other applicable privacy laws governing the protection of personal information under the control of the Department of Employment and Social Development. Survey responses will not be attributed to individuals.

If you wish to obtain information related to this survey, you may submit a request to the Department of Employment and Social Development pursuant to the Access to Information Act. Instructions for making a request are provided in the publication InfoSource, copies of which are located in local Service Canada Centres.

You have the right to file a complaint with the Privacy Commissioner of Canada regarding the institution’s handling of your personal information at: How to file a complaint.

When making a request, please refer to the name of this survey: Report a Problem or Mistake on This Page.